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MUNICIPAL MANAGER DR S VATALA ADVERTISEMENT DATE: 25 November 2019 RFQ NUMBER: 119/2019/20 DESCRIPTION OF GOODS/SERVICES: Appointment of OHS Agent_North & North East BWS_T53 of 2017/2018 RFQ DOCUMENTS ARE OBTAINABLE FROM: Supply Chain Management Section Clyde Street Knysna or Knysna Municipality website: www.knysna.gov.za (Information centre>SCM>QUOATIONS) CLOSING DATE: TIME: 03 Dec 2019 12:00 SUBMISSIONS: Sealed quotations clearly marked, RFQ:OHS Agent_North & North East BWS_T53 of 2017/2018, can be submitted: By hand to: Supply Chain Management Section Knysna Municipality Clyde Street Knysna By fax to: 086 650 1415 By email to: [email protected] Contact person: Sandra Fourie (Tel: 044 302 6328) Electronic bid documents must reach the Supply Chain Management Section before the closing time. COMPULSORY REQUIREMENTS: Health and Safety agent has to provide proof of registration with the SACPCMP TECHNICAL ENQUIRIES: Contact Persons : Bryan Campher Email : [email protected] Tel : 044-3026435 The following conditions will apply: Price(s) quoted must be firm and must be inclusive of VAT when applicable. Attached KMBD6.1 must be completed to qualify for B-BBEE Status Level of Contribution. Tax Clearance Certificate or Sufficient Evidence that Tax matters are raised with SARS must be attached. An original or certified copy of B-BBEE Certificate must be attached to qualify for points. Price must include all related expenses, i.e. transport etc. Attached KMBD 4 document must be completed. Status of Municipal accounts must be submitted. More than 1 supplier could be appointed. Invoices must be submitted to [email protected] and will be paid within 30 days of delivering the service.

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Page 1: Health and Safety agent has to provide proof of ... · 1.3.1 The maximum points for this bid are allocated as follows: POINTS 1.3.1.1 Price 80 1.3.1.2 B-BBEE status level of contribution

MUNICIPAL MANAGER DR S VATALA

ADVERTISEMENT DATE:

25 November 2019

RFQ NUMBER: 119/2019/20

DESCRIPTION OF GOODS/SERVICES:

Appointment of OHS Agent_North & North East BWS_T53 of 2017/2018

RFQ DOCUMENTS ARE OBTAINABLE FROM:

Supply Chain Management Section Clyde Street Knysna or Knysna Municipality website: www.knysna.gov.za (Information centre>SCM>QUOATIONS)

CLOSING DATE: TIME:

03 Dec 2019 12:00

SUBMISSIONS: Sealed quotations clearly marked, “RFQ:OHS Agent_North & North East BWS_T53 of 2017/2018”, can be submitted: By hand to: Supply Chain Management Section Knysna Municipality Clyde Street Knysna By fax to: 086 650 1415 By email to: [email protected] Contact person: Sandra Fourie (Tel: 044 302 6328) Electronic bid documents must reach the Supply Chain Management Section before the closing time.

COMPULSORY REQUIREMENTS: Health and Safety agent has to provide proof of registration with the SACPCMP

TECHNICAL ENQUIRIES:

Contact Persons : Bryan Campher Email : [email protected] Tel : 044-3026435

The following conditions will apply:

Price(s) quoted must be firm and must be inclusive of VAT when applicable.

Attached KMBD6.1 must be completed to qualify for B-BBEE Status Level of Contribution.

Tax Clearance Certificate or Sufficient Evidence that Tax matters are raised with SARS must be attached.

An original or certified copy of B-BBEE Certificate must be attached to qualify for points.

Price must include all related expenses, i.e. transport etc.

Attached KMBD 4 document must be completed.

Status of Municipal accounts must be submitted.

More than 1 supplier could be appointed.

Invoices must be submitted to [email protected] and will be paid within 30 days of delivering the service.

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REQUIREMENTS: OHS Agent North & North East BWS_T53 of 2017/2018 EVALUATION All bids will be evaluated by a panel on basis of functionality (100%) and Price 80. The points scored for functionality will not be carried over to price, but will only be used as a gate keeping exercise. The final evaluation will be done in terms of the Council’s Preferential Procurement Policy which states 80 for price and the remaining 20 for B-BBEE. Point’s allocation for functionality

1. Proof of experience on similar projects or jobs. (Approved orders can be attached as proof) (15)

2. List of contactable references of similar services previously done. (15)

EVALUATION SCHEDULE *** (Your pricing schedule will not be considered if proof relating to this table is not attached to this document)

Criteria Scoring criteria Points Claimed

Proof of experience on similar projects or jobs. (Approved orders can be attached as proof)

Years 1 - 2(5) 3 - 4(10) 5 + (15)

Provide a list of contactable references of similar services previously provided

1 ref (5) 2 refs (10) 3 refs or more (15)

Total 30

Tenderers must achieve a minimum of 20 points in order to qualify for further evaluation on price and preference points

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SPECIFICATIONS:

SPECIFICATIONS 1. Legal framework of the appointment

Under the current Construction regulations, the responsibilities and liabilities to ensure health and safety on a project remain with client and failure to comply with these regulations is a criminal offence.

As set out on regulation 5(6) of the Regulations, the client may appoint a competent person as an Agent in writing to act as the client’s shall as far as is reasonably practicable, apply to the appointed Agent.

2. Proposed scope of work

The scope of work of the Agent will in general cover the requirements of regulation 5 of the Regulations. More specifically, it will entail the following:

2.1 Provide a project specific health and safety specification to the Principal Contractor. A general

specification has been done by the Client by including this specification in the tender documents which the tenderers cost to comply with the Regulations in their tenders.

2.2 Ensure that the principal contractor to be appointed has the necessary competencies and

resources to carry out the construction work safely. 2.3 Take reasonable steps to ensure all contractors appointed by the client to comply with these

Regulations. 2.4 Ensure before any work commences on a site that the principal contractor is registered and in

good standing with the compensation fund or with a licensed compensation insurer as contemplated in the Compensation for Occupational injuries and Diseases Act, 1993 (Act No.130 of 1993).

2.5 Discuss and negotiate with the Principal Contractor the contents of his draft health and safety

plan for final approval for implementation to ensure that it covers all the aspects it is required to in terms of the Act. This will be done as soon as is practicable after the Contractor has been appointed but before any construction work is executed.

2.6 Finally approve the health and safety plan implementation. This will also be done before the

Contractor will be allowed to commence with the construction work/ 2.7 Take reasonable steps to ensure each contractor’s health and safety plan contemplated in

regulation 7(1) (a) is implemented and maintained. 2.8 Ensure that periodic health and safety audits and document verification are conducted at

intervals mutually agreed upon between the principal contractor and any contractor, but at least every 14 days.

2.9 Ensure that a copy of the health and safety audit report contemplated in the paragraph above is

provided to the principal contractor within seven days after the audit. 2.10 Stop any contractor from executing a construction activity which poses a threat to the health

and safety of persons which is not in accordance with the client’s health and safety specifications and the principal contractor’s health and safety plan for the site.

2.11 Ensure that the health and safety file contemplated in regulation 7(1) (b) is kept and maintained

by the principal contractor. 2.12 Manage the health and safety and monitor the execution of the construction work to ensure that

this is being done in accordance with the Contractor’ health and safety plan in this contract.

Monitoring by the Agent will be carried out at an absolute minimum of 2 times per month, but the responsibility remains with the Agent to ensure that all Health and Safety requirements are adhered to, thus inspections may be required on a weekly or daily basis.

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Monitoring will consist of a walk through inspection of the site together with the auditing of all

register and documents the Principal Contractor and Sub-Contractors are required to maintain. A monthly non-compliance report must be submitted to the client in which all instances where

the Principal Contractor has deviated from the requirements of his health and safety plan. Together with the actions taken by the Agent, will be recorded.

2.13 On completion of the contract, all relevant documentation generated by the Principal Contractor

as well as a final non-compliance report must be submitted to the client. 3. Contract data It is expected that construction has begun in December 2019 and end in May 2020.

Construction value is expected to be approximately R23.million. The work will be done over three (3) financial years and is in four (4) different areas; this work will cover the following:

a) Concordia zone

Add Bongani (top of valley zone) to Concordia Reservoir zone or High level zone (pipework) b) DAM SE BOS ZONE (INCL.HLALANI, OUPAD, NEKKIES)

New Dam se Bos pumps and pipeline/pipework

New Dam se Bos high level zone (pipework)

c) HEIDEVALLEI

New PS to Heidevallei Q=74l/s

New Rising Main (RM) to Heidevallei, 200mm Ø uPVC (approximately 1500m)

New Heidevallei 3ML Reservoir We expect one to two construction teams to be on site. The successful Agent will be expected

to be on site at sufficient intervals and for sufficient time to ensure adequate supervision. 4. The proposed set out of your quotation should be as follows: 4.1 Proposed personnel The role of Agent will collectively be fulfilled by the following staff members: ………………………. ………………………. ……………………… 4.2 Estimated budget 4.2.1 The budget which is proposed below is based on the following assumptions: A construction period of 6 months. Assumed at least two visits per month i.e. 12 visits required

(See item 2.12). The Principal Contractor has a good understanding of his responsibilities in terms of the Act,

and therefore being able to prepare a good quality draft health and safety plan. In other words we have not allowed for “training” the contractor in this regard.

4.2.2 Proposed budget Compile in liaison with Client a project specific health and safety specification: R………………. Discus and comment on contractor’s draft plan: R…………….... Approve final H&S plan: R……………….

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Monitoring the execution of the construction work for 5 months (say) 2 visits per month i.e. 10 visits): R…................. Project management: R……………. Quality control of process: R……………. Total estimated cost: R……………... The budget amounts are exclusive of VAT 4.2.3 Frequency of invoicing.

Invoices will be submitted directly to the Client on a monthly basis on the basis of the work completed up to that point.

5. Find enclosed with this letter the extract of the tender document with respect to the extent of the work as well as general health and safety specifications for your use and comments.

6. Conclusion

Should your quotation be successful you would be appointed directly by the Knysna Municipality in terms of their standard conditions for Service Providers.

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Contact Details of Tenderer

Knysna Municipality Supplier number

CSD Supplier number

CSD Unique Registration Reference Number

The name of the Tenderer:

The name of the contact person:

The address of the Tenderer:

Telephone:

Facsimile:

E-mail:

Address (physical):

Address (postal):

Signature:

Date:

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MBD 6.1 PREFERENCE POINTS CLAIM FORM IN TERMS OF THE PREFERENTIAL

PROCUREMENT REGULATIONS 2017

This preference form must form part of all bids invited. It contains general information and serves as a claim form for preference points for Broad-Based Black Economic Empowerment (B-BBEE) Status Level of Contribution

NB: BEFORE COMPLETING THIS FORM, BIDDERS MUST STUDY THE GENERAL CONDITIONS, DEFINITIONS AND DIRECTIVES APPLICABLE IN RESPECT OF B-BBEE, AS PRESCRIBED IN THE PREFERENTIAL PROCUREMENT REGULATIONS, 2017. 1. GENERAL CONDITIONS 1.1 The following preference point systems are applicable to all bids:

- the 80/20 system for requirements with a Rand value of up to R50 000 000 (all applicable taxes included); and

- the 90/10 system for requirements with a Rand value above R50 000 000 (all applicable taxes included). 1.2 The value of this bid is estimated not to exceed R200 000 (all applicable taxes included) and therefore the

80/20 system shall be applicable. 1.3 Preference points for this bid shall be awarded for:

(a) Price; and (b) B-BBEE Status Level of Contribution.

1.3.1 The maximum points for this bid are allocated as follows:

POINTS

1.3.1.1 Price 80

1.3.1.2 B-BBEE status level of contribution 20

Total points for Price and B-BBEE must not exceed 100

1.4 Failure on the part of a bidder to fill in and/or to sign this form and submit a B-BBEE Verification Certificate from a Verification Agency accredited by the South African Accreditation System (SANAS) or a Registered Auditor approved by the Independent Regulatory Board of Auditors (IRBA) or an Accounting Officer as contemplated in the Close Corporation Act (CCA) together with the bid, will be interpreted to mean that preference points for B-BBEE status level of contribution are not claimed.

1.5. The purchaser reserves the right to require of a bidder, either before a bid is adjudicated or at any time subsequently, to substantiate any claim in regard to preferences, in any manner required by the purchaser.

2. DEFINITIONS 2..1 “all applicable taxes” includes value-added tax, pay as you earn, income tax, unemployment insurance fund

contributions and skills development levies; 2.2 “B-BBEE” means broad-based black economic empowerment as defined in section 1 of the Broad-Based

Black Economic Empowerment Act; 2.3 “B-BBEE status level of contributor” means the B-BBEE status received by a measured entity based on its

overall performance using the relevant scorecard contained in the Codes of Good Practice on Black Economic Empowerment, issued in terms of section 9(1) of the Broad-Based Black Economic Empowerment Act;

2.4 “bid” means a written offer in a prescribed or stipulated form in response to an invitation by an organ of state for the provision of services, works or goods, through price quotations, advertised competitive bidding processes or proposals;

2.5 “Broad-Based Black Economic Empowerment Act” means the Broad-Based Black Economic Empowerment Act, 2003 (Act No. 53 of 2003);

2.6 “comparative price” means the price after the factors of a non-firm price and all unconditional discounts that can be utilized have been taken into consideration;

2.7 “consortium or joint venture” means an association of persons for the purpose of combining their expertise, property, capital, efforts, skill and knowledge in an activity for the execution of a contract;

2.8 “contract” means the agreement that results from the acceptance of a bid by an organ of state; 2.9 “EME” means any enterprise with an annual total revenue of R5 million or less

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2.10 “Firm price” means the price that is only subject to adjustments in accordance with the actual increase or decrease resulting from the change, imposition, or abolition of customs or excise duty and any other duty, levy, or tax, which, in terms of the law or regulation, is binding on the contractor and demonstrably has an influence on the price of any supplies, or the rendering costs of any service, for the execution of the contract;

2.11 “functionality” means the measurement according to predetermined norms, as set out in the bid documents, of a service or commodity that is designed to be practical and useful, working or operating, taking

into account, among other factors, the quality, reliability, viability and durability of a service and the technical capacity and ability of a bidder;

2.12 “non-firm prices” means all prices other than “firm” prices; 2.13 “person” includes a juristic person; 2.14 “rand value” means the total estimated value of a contract in South African currency, calculated at the time

of bid invitations, and includes all applicable taxes and excise duties; 2.15 “total revenue” bears the same meaning assigned to this expression in the Codes of Good Practice on Black

Economic Empowerment, issued in terms of section 9(1) of the Broad-Based Black Economic Empowerment Act and promulgated in the Government Gazette on 9 February 2007;

2.16 “trust” means the arrangement through which the property of one person is made over or bequeathed to a trustee to administer such property for the benefit of another person; and

2.17 “trustee” means any person, including the founder of a trust, to whom property is bequeathed in order for such property to be administered for the benefit of another person.

3. ADJUDICATION USING A POINT SYSTEM 3.1 The bidder obtaining the highest number of total points will be awarded the contract. 3.2 Preference points shall be calculated after prices have been brought to a comparative basis taking into account

all factors of non-firm prices and all unconditional discounts;. 3.3 Points scored must be rounded off to the nearest 2 decimal places. 3.4 In the event that two or more bids have scored equal total points, the successful bid must be the one scoring

the highest number of preference points for B-BBEE. 3.5 However, when functionality is part of the evaluation process and two or more bids have scored equal points

including equal preference points for B-BBEE, the successful bid must be the one scoring the highest score for functionality.

3.6 Should two or more bids be equal in all respects, the award shall be decided by the drawing of lots. 4. POINTS AWARDED FOR PRICE 4.1 THE 80/20 OR 90/10 PREFERENCE POINT SYSTEMS A maximum of 80 or 90 points is allocated for price on the following basis: 80/20 or 90/10

min

min180

P

PPtPs or

min

min190

P

PPtPs

Where Ps = Points scored for comparative price of bid under consideration Pt = Comparative price of bid under consideration Pmin = Comparative price of lowest acceptable bid 5. Points awarded for B-BBEE Status Level of Contribution 5.1 In terms of Regulation 5 (2) and 6 (2) of the Preferential Procurement Regulations, preference points must be

awarded to a bidder for attaining the B-BBEE status level of contribution in accordance with the table below: 5.2

Bidders who qualify as EMEs in terms of the B-BBEE Act must submit a certificate issued by an Accounting Officer as contemplated in the CCA or a Verification Agency accredited by SANAS or a Registered

B-BBEE Status Level of Contributor

Number of points

(90/10 system)

Number of points

(80/20 system)

1 10 20

2 9 18

3 6 14

4 5 12

5 4 8

6 3 6

7 2 4

8 1 2

Non-compliant contributor 0 0

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Auditor. Registered auditors do not need to meet the prerequisite for IRBA’s approval for the purpose of conducting verification and issuing EMEs with B-BBEE Status Level Certificates.

5.3 Bidders other than EMEs must submit their original and valid B-BBEE status level verification certificate or a certified copy thereof, substantiating their B-BBEE rating issued by a Registered Auditor approved by IRBA or a Verification Agency accredited by SANAS.

5.4 A trust, consortium or joint venture, will qualify for points for their B-BBEE status level as a legal entity, provided that the entity submits their B-BBEE status level certificate.

5.5 A trust, consortium or joint venture will qualify for points for their B-BBEE status level as an unincorporated entity, provided that the entity submits their consolidated B-BBEE scorecard as if they were a group structure and that such a consolidated B-BBEE scorecard is prepared for every separate bid.

5.6 Tertiary institutions and public entities will be required to submit their B-BBEE status level certificates in terms of the specialized scorecard contained in the B-BBEE Codes of Good Practice.

6. BID DECLARATION 6.1 Bidders who claim points in respect of B-BBEE Status Level of Contribution must complete the following:

6.1.2 B-BBEE STATUS LEVEL OF CONTRIBUTION CLAIMED IN TERMS OF PARAGRAPHS 1.3.1.2 AND 5.1

6.1.2.1 B-BBEE Status Level of Contribution as reflected on the B-BBEE Certificate

6.1.2.2 Points claimed in respect of Level of Contribution (maximum of 10 or 20 points Points claimed in respect of paragraph 6.1 must be in accordance with the table reflected in paragraph 5.1 and

must be substantiated by means of a B-BBEE certificate issued by a Verification Agency accredited by SANAS or a Registered Auditor approved by IRBA or an Accounting Officer as contemplated in the CCA

7. SUB-CONTRACTING

7.1. Will any portion of the contract be sub-contracted? (Tick applicable box) YES NO

7.1.1. If yes, indicate:

7.1.1.1. what percentage of the contract will be subcontracted? %

7.1.1.2. the name of the sub-contractor?

7.1.1.3. the B-BBEE status level of the sub-contractor?

7.1.1.4. whether the sub-contractor is an EME? (Tick applicable box) YES NO

8 DECLARATION WITH REGARD TO COMPANY/FIRM

8.1

Name of Company / Firm

8.2

VAT Registration number

8.3

Company Registration number

8.4

Type of Company / Firm

(Tick Applicable Box)

Partnership/Joint Venture / Consortium

One person business/sole propriety

Close corporation

Company

(Pty) Limited

8.5

Describe Principal Business

Activities

8.6

Company Classification (Tick Applicable Box)

Manufacturer

Supplier

Professional Service Provider

Other service providers, eg transporter 8.7 TOTAL NUMBER OF YEARS THE ENTERPRISE HAS BEEN IN BUSINESS

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9. I/we, the undersigned, who is / are duly authorised to do so on behalf of the company/firm, certify that the points claimed, based on the B-BBE status level of contribution indicated in paragraph 7 of the foregoing certificate, qualifies the company/ firm for the preference(s) shown and I / we acknowledge that:

(i) The information furnished is true and correct; (ii) The preference points claimed are in accordance with the General Conditions as indicated in

paragraph 1 of this form. (iii) In the event of a contract being awarded as a result of points claimed as shown in paragraph 7, the

contractor may be required to furnish documentary proof to the satisfaction of the purchaser that the claims are correct;

(iv) If the B-BBEE status level of contribution has been claimed or obtained on a fraudulent basis or any of the conditions of contract have not been fulfilled, the purchaser may, in addition to any other remedy it may have –

(a) disqualify the person from the bidding process; (b) recover costs, losses or damages it has incurred or suffered as a result of that person’s

conduct; (c) cancel the contract and claim any damages which it has suffered as a result of having to make

less favourable arrangements due to such cancellation (d) restrict the bidder or contractor, its shareholders and directors, or only the shareholders and

directors who acted on a fraudulent basis, from obtaining business from any organ of state for a period not exceeding 10 years, after the audi alteram partem (hear the other side) rule has been applied; and

(e) forward the matter for criminal prosecution

NAME OF BIDDER

DATE

SIGNATURE

WITNESS 1

WITNESS 2

WITNESS 1

DATE

DATE

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MBD 4 DECLARATION OF INTEREST

1. No bid will be accepted from persons in the service of the state¹.

2. Any person, having a kinship with persons in the service of the state, including a blood relationship, may make an offer or offers in terms of this invitation to bid. In view of possible allegations of favouritism, should the resulting bid, or part thereof, be awarded to persons connected with or related to persons in service of the state, it is required that the bidder or their authorised representative declare their position in relation to the evaluating/adjudicating authority.

3. In order to give effect to the above, the following questionnaire must be completed and submitted with the bid.

3.1

Full Name of bidder or his or her representative:

3.2

Identity Number:

3.3

Position occupied in the Company (director, trustee, hareholder²):

3.4

Company Registration Number:

3.5

Tax Reference Number:

3.6

VAT Registration Number:

3.7 The names of all directors / trustees / shareholders members, their individual identity numbers and state employee numbers must be indicated in paragraph 4 below.

3.8 Are you presently in the service of the state? YES NO

3.8.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

3.9 Have you been in the service of the state for the past twelve months? YES NO

3.9.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

3.10 Do you have any relationship (family, friend, other) with persons in the service of the state and who may be involved the evaluation and or adjudication of this bid?

YES NO

3.10.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

3.11 Are you, aware of any relationship (family, friend, other) between any other bidder and any persons in the service of the state who may be involved with the evaluation and or adjudication of this bid

YES NO

3.11.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

3.12 Are any of the company’s directors, trustees, managers, principle shareholders or stakeholders in service of the state?

YES NO

3.12.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

3.13 Are any spouse, child or parent of the company’s directors, trustees, managers, principle shareholders or stakeholders in service of the state?

YES NO

3.13.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

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3.14 Do you or any of the directors, trustees, managers, principle shareholders, or stakeholders of this company have any interest in any other related companies or business whether or not they are bidding for this contract

YES NO

3.14.1 If yes, furnish particulars: _______________________________________________________________________________________

______________________________________________________________________________________

¹MSCM Regulations: “in the service of the state” means to be –

(a) a member of – (i) any municipal council; (ii) any provincial legislature; or (iii) the national Assembly or the national Council of provinces;

(b) a member of the board of directors of any municipal entity; (c) an official of any municipality or municipal entity; (d) an employee of any national or provincial department, national or provincial public entity or constitutional

institution within the meaning of the Public Finance Management Act, 1999 (Act No.1 of 1999); (e) a member of the accounting authority of any national or provincial public entity; or (f) An employee of Parliament or a provincial legislature.

² Shareholder” means a person who owns shares in the company and is actively involved in the management of the company or business and exercises control over the company.

4. Full details of directors / trustees/ members / shareholders:

Full Name Identity Number State Employee Number

5. I, the undersigned (name) __________________________________________, certify that the information furnished in

paragraphs 3 and 4 above is correct. I accept that the state may act against me should this declaration prove to be false.

Name of Bidder

Date

Signature

Capacity

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11. MDB 15 – Certificate for Payment of Municipal Services

NAME OF THE BIDDER: FURTHER DETAILS OF THE BIDDER’S; Director / Shareholder / Partners, etc:

Director / Shareholder / partner Physical address of

the Business

Municipal Account

number(s)

Physical residential address of the Director /

shareholder / partner

Municipal Account number(s)

NB: Please attach certified copy (ies) of ID document(s)

I, ,

(Full name in block letters) the undersigned, certify that the information furnished on this declaration form is correct and that I / we

have no undisputed commitments for municipal services towards a municipality in respect of which payment is overdue for more

than 90 days.

If the value of the transaction is expected to exceed R10 million (VAT included) I certify that the bidder has no undisputed

commitments for municipal services towards a Municipality in respect of which payment is overdue for more than 30 days;

THUS DONE AND SIGNED for and on behalf of the Bidder, at , on the

day of 20 .

Number of sheets appended by the tenderer to this schedule (If nil, enter NIL)

SIGNATURE: NAME (PRINT):

CAPACITY: NAME OF FIRM:

For office use (comments):